Chain of bad decisions fatal for three

The pilot, who was conducting a local personal flight in the Piper PA-28-140 with three passengers onboard, was departing from a turf and sand-covered runway in Fountain, Florida, that had a usable length of 2,600 feet.

Although a relatively clear area was located beyond one end of the runway, he elected to depart in the opposite direction toward a heavily forested area with trees that were about 70 feet tall.

After a takeoff run requiring about half of the runway’s available length, the plane began climbing at an abnormally steep angle. It climbed above the trees at the departure end of the runway, stopped climbing, rolled to the right, descended into the trees, and hit the ground, killing three of those aboard and seriously injuring the fourth.

A post-impact fire consumed the majority of the airplane.

Review of video recorded both onboard and from outside the airplane showed that the pilot did not use the manufacturer’s recommended procedure for a takeoff from a turf (soft) runway with obstacles ahead.

The procedure called for 25° of flaps, and he used no flaps.

Further, the procedure called for the pilot to raise the nose wheel off the ground as soon as possible, takeoff at the lowest possible airspeed, and accelerate to 78 mph before climbing. The pilot did none of these.

The video also showed that he elected to depart with a slight prevailing tailwind.

While the estimated velocity of the tailwind was only 3 knots, this tailwind may have increased the airplane’s takeoff distance by as much as 15%.

Additionally, the calculated density altitude of 1,900 feet resulted in an estimated additional 20% increase in the takeoff distance and an estimated 10% reduction in rate of climb once the airplane was airborne.

The video showed that, during the takeoff, the engine tachometer indicated an rpm of about 2,000, which was less than the published minimum static rpm of 2,325 for the engine at its maximum throttle setting.

While the accuracy of the tachometer’s calibration could not be verified due to damage sustained during the accident, one potential cause for this discrepancy was the position of the carburetor heat selector handle.

Video and statements from the airplane’s owner suggest that the pilot had left the selector in an intermediate position, although the appropriate position for the takeoff phase of flight was the off position.

Taking off with the selector in an intermediate position would potentially result in a loss of engine performance consistent with that observed on the tachometer.

The NTSB determined the probable cause as the pilot’s decision to depart from a soft runway with a tailwind and toward obstructions, and his failure to follow the manufacturer’s recommended procedures for the takeoff.

Contributing to the accident were the degradation of airplane and engine performance due to the high density altitude and the pilot’s failure to properly configure the airplane’s carburetor heat.

I looked at the NTSB’s Full Narrative on this accident which is very interesting. The chain of poor decisions goes back even further. The owner of the aircraft, had just a few days before, checked the pilot out in the aircraft. The low time pilot (148 total flight time) had been taught by the aircraft owner incorrect techniques for soft field takeoff. In addition the aircraft did not have up-to-date weight and balance data. These are just a few of the problems that led to this accident. If interested here is a link to the NTSB full report: (http://www.ntsb.gov/_layouts/ntsb.aviation/brief2.aspx?ev_id=20140525X21418&ntsbno=ERA14FA255&akey=1)

The lack of experience and bad advice is what contributed, greatly in my opinion, in this tragedy. Who amongst us have not gotten bad advice in our training? I have, and when I realized the truth, it is quite disheartening and a bit alarming. This fellow learned the hard way and it is bad enough that he has to live with his injuries and tragedy that we should stop beating a dead horse, and keep our critical opinions to ourselves whilst learn from this experience to the betterment of ourselves. Remember, aviation is one hell of a teacher, it gives you the exam before the lesson.

Wow just wow. This guy could have benefited from the many free resources on the internet helping maintain proficiency and knowledge on common operations. This to me is sad, because it was preventable in may ways and most likely the families of the passengers no longer care to support GA.

Jay,
You are correct, there are lots of resources available to pilots. Aviation Safety seminars are held all over the country all the time. The biggest problem is, those pilots that need to go, don’t. The pilots attending are the safe pilots and they know who the pilots are that should be there. If for nothing else, many of the seminars usually provide food or at least snacks.

Pilots, please, please, do your best to get these marginal pilots to attend safety seminars, take recurrent training, or maybe just hire a CFI for a few hours of dual.